Clinical factors influencing the prescription of antidepressants and benzodiazepines: results from the European study of the epidemiology of mental disorders (ESEMeD)

Distinct Regional Pattern of Sedative Psychotropic Drug Use in South Tyrol: A Comparison with National Trends in Italy

This study investigated regional variations in the use of sedative psychotropic medications, often prescribed for insomnia, by comparing Italy and the culturally distinct Autonomous Province of Bolzano, South Tyrol. Using daily defined dose (DDD) data per 1000 inhabitants per day, benzodiazepines, Z-drugs, sedative antidepressants, and melatonin consumption from 2019 to 2023 were examined. The findings indicate a notably lower utilization of benzodiazepines in South Tyrol compared to the national Italian average, alongside a significant increase in sedative antidepressant use, particularly mirtazapine. These disparities likely stem from regional prescribing preferences influenced by cultural, linguistic, and healthcare system factors. While Z-drug consumption remained comparable across regions, melatonin use exhibited a gradual upward trend, albeit less pronounced in South Tyrol. These insights emphasize the necessity for region-specific strategies in optimizing insomnia treatment, balancing pharmacological approaches with non-pharmacological alternatives such as cognitive behavioral therapy for insomnia. Understanding these prescribing trends can inform healthcare policies aimed at reducing long-term sedative use while enhancing patient-centered care in sleep medicine.

Prescription of benzodiazepines and Z-drugs among older patients in primary care: a French, national, cohort study

BACKGROUND

In France, general practitioners (GPs) prescribe benzodiazepines and Z-drugs (BZD/ZDs) widely, and especially to older adults. Several characteristics of patients and/or GPs linked to BZD/ZD overprescription have been described in the general population but not among older patients in primary care.

OBJECTIVES

To estimate the proportion of GP consultations by patients aged 65 and over that resulted in a BZD/ZD prescription, and determine whether any GP-related factors predicted BZD/ZD overprescription in this setting.

METHODS

We analyzed sociodemographic and practice-related GP characteristics, and aggregated data on consultations recorded prospectively by 117 GPs in a database between 2000 and 2010. Next, we used logistic regression models to look for factors potentially associated with BZD/ZD overprescription (defined as an above-median prescription rate).

RESULTS

The GPs' mean age at inclusion was 47.4 (7.1), and 87.9% were male. During the study period, the median (95% confidence interval) proportion of consultations with patients aged 65 and over resulting in a BZD/ZD prescription was 21.8% (18.1-26.1) (range per GP: 5-34.1%). In a multivariable analysis, a greater number of chronic disease (OR [95% CI] = 2.10 [1.22-3.64]), a greater number of drugs prescribed per consultation (5.29 [2.72-10.28]), and shorter study participation were independently associated with BZD/ZD overprescription.

CONCLUSIONS

BZD/ZD overprescription was associated with a greater chronic disease burden and the number of drugs prescribed per consultation but not with any sociodemographic or practice-related GP characteristics. Targeted actions are needed to help GPs limit their prescription of BZD/ZDs to older patients with multiple comorbidities and polypharmacy.

Sertraline versus escitalopram in South Asians with moderate to severe major depressive disorder: (SOUTH-DEP) a double-blind, parallel, randomized controlled trial

Objective

The study design included the double-blind, parallel, randomized controlled trial. The aim of this randomized controlled trial was to compare the efficacy and safety of sertraline and escitalopram in participants with moderate to severe major depressive disorder (MDD).

Methods

The study was conducted in South Asian participants. A total of 744 participants with moderate to severe MDD were randomly assigned to receive either sertraline or escitalopram for 8 weeks. Drug dosages and titration schedules were based on the recommendations of the prescribing information for each product and according to the judgment of the clinicians involved in the study. The primary outcome measures were changes from baseline on the Montgomery-Åsberg Depression Rating Scale (MADRS) and the clinical global impression (CGI) scale as well as the frequency of adverse events in both groups. Baseline MADRS scores in the escitalopram and sertraline groups were 28.2±0.47 (mean±SD) and 29.70±0.46 (mean±SD) respectively, and was no variability in the baseline assessments. Changes in MADRS as well as CGI scales at the end of the study were significant only for the sertraline group whereas they remained statistically nonsignificant for the escitalopram group. Results: The results of the study showed that sertraline was more efficacious than escitalopram in reducing depression rating scales such as MADRS and CGI, and that participants subjectively felt better regarding their symptoms in the sertraline group. Sertraline displays enhanced safety or tolerability than other groups of antidepressants, which frequently cause high levels of drowsiness, dizziness, blurred vision, and other undesirable effects. Adverse events were seen in both groups, but delayed ejaculation was the most frequent adverse event seen in both groups. However, a greater number of participants reported having nausea and insomnia in the sertraline group compared to the escitalopram group.

Conclusion

Our study clearly highlights that there is a statistically significant difference in efficacy between sertraline and escitalopram at the doses used in our study. Sertraline was able to significantly lower the depression rating scales like MADRS and CGI in participants with moderate to severe MDD. Participants subjectively felt better regarding their symptoms in the sertraline group. The most frequent adverse event in both groups was delayed ejaculation. From an efficacy standpoint, sertraline was more efficacious than escitalopram. The study indicates that the prevalence of depressive disorders in South Asia is comparable to the global estimate, and Bangladesh and India has higher proportions of people with depressive disorders in South Asia. Additionally, females and older adults (75-79 years) have the highest burden of depressive disorders across all countries in the region. This study's limitation included the absence of a placebo arm. An additional limitation of the current study was the lack of an evaluation of inter-rater reliability and the research sample could not have been uniform in terms of the kind of depressive disorders and bipolarity.

The Italian consensus conference on psychological therapies for anxiety and depressive disorders: findings and recommendations

A Consensus Conference of clinicians, researchers, public health specialists and users was convened in Italy to review efficacy, effectiveness, treatment appropriateness and access to care for anxiety and depression, and to consider the role of psychological therapies. Expert opinion was sought concerning identification of people requiring psychological therapies according to levels of symptom severity matched to corresponding levels of treatment intensity, suitability of psychological therapies for subclinical anxiety or depression, definition of a minimum level of information on evidence-based psychotherapies to be provided by university medical and psychology courses, initiatives to raise awareness among potential users and decision makers on the role and effectiveness of psychological therapies in healthcare. The expert jury concluded that a number of psychological therapy models endorsed by most authoritative guidelines are supported by research showing their effectiveness at least equal to the drugs used in common mental disorders (CMDs). Such therapies are under-represented in the Italian public health system, leading many people to resort to the private sector, resulting in unacceptable wealth discrimination. The difficulty of accessing psychological treatments often entails the use of drug therapies in cases where they are not indicated. Starting from these assumptions, the experts recommended the promotion of better and timely recognition of anxiety and depressive disorders and their classification in terms of symptom intensity and functional impairment, differentiating subthreshold mood swings from clinical forms, to foster outcome studies of psychotherapies in CMDs in Italy, to introduce a stepped care model structured according to levels of intensity of treatment, based on wellbeing support strategies in nonmedical contexts for subthreshold situations, self-help, support and psychoeducation as frontline interventions in mild clinical forms, evidence-based psychotherapies in moderate and severe forms, with the option of combining psychological treatment and appropriate drug therapy in the most severe cases.

An examination of the medicalization and pharmaceuticalization processes of anxiety and depressive disorders in Belgium between 2004 and 2013: how may both disorders be intertwined?

Background

While medicalization and pharmaceuticalization trends of feelings of anxiety and depression have been described in great detail, an empirical examination of these trends is to date lacking. The current study fills this gap in the literature by mapping the use of psychotropic medicines for feelings of anxiety and depression between 2004 and 2013 in Belgium, as well as by examining whether a social gradient might act as a mediator.

Methods

We analyzed data from three repeated cross-sectional waves (2004, 2008, and 2013) of the Belgian National Health Interview Survey (HIS). Multinomial logistic regression was applied to estimate odds in psychotropic drugs use over the observed period.

Results

Using an ideal-typical distinction between traditional anxiety drugs (psycholeptics) and depression drugs (psychoanaleptics), we found that treatment methods for feelings of anxiety and depression were converging. Persons having feelings of anxiety consumed less psycholeptic drugs, in favor of psychoanaleptic drugs throughout the observed period. Moreover, these results were partially mediated by educational level. Persons with higher education were less likely to consume psychotropic drugs than those with lower education, suggesting a trend of demedicalization for feelings of anxiety and depression.

Limitations

Our study observes a limited period, makes use of an ideal typical distinction between psycholeptic and psychoanaleptic drugs, and measurements may be biased by response-bias due to psychotropic drugs use.

Conclusion

Our study shows that psycholeptics increasingly give way to psychoanaleptics in the treatment of both anxiety and depression, despite several scientists calling their effectiveness for both disorders into question.

Risk of fracture in antidepressant users with concurrent use of benzodiazepines: A self-controlled case-series analysis

OBJECTIVE

Despite the fracture risk associated with both antidepressant (AD) medication and benzodiazepines (BDZs), they are commonly prescribed simultaneously. However, studies elucidating the effects of concurrent use of BDZs and ADs on the risk fracture are scant. The objective of this study was to evaluate the risk of fracture associated with concurrent use of BDZs in AD users, using a self-controlled case-series analysis.

METHODS

A self-controlled case-series analysis, in which the participants act as their own control, was conducted using the Korean National Health Insurance Service-National Sample Cohort database (2002-2015). We studied AD users who were prescribed BDZs and diagnosed with a fracture. The risk periods were subdivided into consecutive periods (1-30, 31-60, and > 60 days) after receiving a BDZ. A 2-week pre-exposure period and a 2-week post-exposure period were also included. The incidence rate ratio (IRR) was estimated after adjusting for age and use of co-medications.

RESULTS

A total of 3020 patients were identified during the study period. There was an increased fracture risk in the first 30 days following BDZ use (IRR: 1.88, 95% confidence interval [CI] 1.66-2.12), in the 31-60-day period (1.73, 95% CI 1.48-2.02), and beyond the 60-day period (IRR: 1.68, 95% CI 1.47-1.91). The risks of fracture were greater in men and older patients.

CONCLUSION

The concomitant use of BDZs and ADs was related to a significant increase in fracture risk. AD users should be aware of the fracture risk with concomitant BDZ use, especially for first-time BDZ users and for elderly patients.

Subgrouping time-dependent prescribing patterns of first-onset major depressive episodes by psychotropics dissection

BACKGROUND

Subgrouping patients with major depressive disorder is a promising solution for the issue of heterogeneity. However, the link between available subtypes and distinct pathological mechanisms is weak and yields disappointing results in clinical application.

AIM

To develop a novel approach for classification of patients with time-dependent prescription patterns at first onset in real-world settings.

METHODS

Drug-naive patients experiencing their first major depressive episode (n = 105) participated in this study. Psychotropic agents prescribed in the first 24 mo following disease onset were recorded monthly and categorized as antidepressants, augmentation agents, and hypnosedatives. Monthly cumulative doses of agents in each category were converted into relevant equivalents. Four parameters were used to summarize the time-dependent prescription patterns for each psychotropic load: Stability, amount, frequency, and the time trend of monthly prescriptions. A K-means cluster analysis was used to derive subgroups of participants based on these input parameters of psychotropic agents across 24 mo. Clinical validity of the resulting data-driven clusters was compared using relevant severity indicators.

RESULTS

Four distinct clusters were derived from K-means analysis, which matches experts’ consent: "Short-term antidepressants use", "long-term antidepressants use", "long-term antidepressants and sedatives use", and "long-term antidepressants, sedatives, and augmentation use". At the first 2 years of disease course, the four clusters differed on the number of antidepressants used at adequate dosage and duration, frequency of outpatient service use, and number of psychiatric admissions. After the first 2 years following disease onset, depression severity was differed in the four subgroups.

CONCLUSION

Our findings suggested a new approach to optimize the subgrouping of patients with major depressive disorder, which may assist future etiological and treatment response studies.

Changes in benzodiazepine use in the French general population after November 2015 terrorist attacks in Paris: an interrupted time series analysis of the national CONSTANCES cohort

OBJECTIVES

To determine whether the terrorist attacks occurring in Paris on November 2015 have changed benzodiazepine use in the French population.

DESIGN

Interrupted time series analysis.

SETTING

National population-based cohort.

PARTICIPANTS

90 258 individuals included in the population-based CONSTANCES cohort from 2012 to 2017.

OUTCOME MEASURES

Benzodiazepine use was evaluated according to two different indicators using objective data from administrative registries: weekly number of individuals with a benzodiazepine delivered prescriptions (BDP) and weekly number of defined daily dose (DDD). Two sets of analyses were performed according to sex and age (≤50 vs >50). Education, income and area of residence were additional stratification variables to search for at-risk subgroups.

RESULTS

Among women, those with younger age (incidence rate ratios (IRR)=1.18; 95% CI=1.05 to 1.32 for BDP; IRR=1.14; 95% CI=1.03 to 1.27 for DDD), higher education (IRR=1.23; 95% CI=1.03 to 1.46 for BDP; IRR=1.23; 95% CI=1.01 to 1.51 for DDD) and living in Paris (IRR=1.27; 95% CI=1.05 to 1.54 for BDP) presented increased risks for benzodiazepine use. Among participants under 50, an overall increase in benzodiazepine use was identified (IRR=1.14; 95% CI=1.02 to 1.28 for BDP and IRR=1.12; 95% CI=1.01 to 1.25 for DDD) and in several strata. In addition to women, those with higher education (IRR=1.22; 95% CI=1.02 to 1.47 for BDP), lower income (IRR=1.17; 95% CI=1.02 to 1.35 for BDP) and not Paris residents (IRR=1.13; 95% CI=1.02 to 1.26 for BDP and IRR=1.13; 95% CI=1.03 to 1.26 for DDD) presented increased risks for benzodiazepine use.

CONCLUSION

Terrorist attacks might increase benzodiazepine use at a population level, with at-risk subgroups being particularly concerned. Information and prevention strategies are needed to provide appropriate care after such events.

Benzodiazepines and antidepressants: Effects on cognitive and functional decline in Alzheimer's disease and Lewy body dementia

OBJECTIVES

We aim to study the effects of the prescription of benzodiazepines and antidepressants on cognitive and functional decline in older adults living with Alzheimer's disease (AD) and Lewy body dementia (LBD) over a 5-year follow-up.

METHODS

This is a longitudinal analysis of a Norwegian cohort study entitled "The Dementia Study of Western Norway" (DemVest). We included 196 patients newly diagnosed with AD (n = 111) and LBD (n = 85), followed annually for 5 years. Three prescription groups were defined: only benzodiazepines (BZD), only antidepressants (ADep), and the combination of benzodiazepines and antidepressants (BZD-ADep). Linear mixed-effects models were conducted to analyze the effect of the defined groups on the outcomes. The outcomes were functional decline, measured by the Rapid Disability Rating Scale-2, and cognition measured with the Mini-Mental State Examination.

RESULTS

Prescription of the combination of benzodiazepines and antidepressants in LBD was associated with faster functional decline. In AD, the prescription of BZD and BZD-ADep was associated with greater functional deterioration. ADep alone did not show positive or negative significant associations with the studied outcomes.

CONCLUSIONS

BZD and especially the combination of BZD and ADep are associated with functional decline in AD and LBD and should be used cautiously.

Evolution of medication consumption in a working environment in France: Results of the four waves of the "Drugs and Work" study (1986-2016)

OBJECTIVES

Previous studies in the working environment have underlined the high prevalence of drug consumption. The aim of this study was to present the main characteristics of this consumption in French workers and to identify changes from the 1986, 1996, 2006 and 2016 surveys.

METHODS

The design was a repeated cross-sectional study in 1986, 1996, 2006 and 2016. At each wave, demographic and socio-professional characteristics, self-reported consumption of medications during the week before the occupational medical visit, and perceived difficult working conditions and extraprofessional problems were collected among a sample of workers. Factors associated with consumption of any drug and of main therapeutic classes were investigated through multivariate logistic regression models, using 2016 as the reference for investigating temporal trends.

RESULTS

Prevalence of use of any drug was significantly higher in 2016, with marked changes observed in comparison with 1986: absolute decrease of psychotropic (-5.1%, p < 0.0001), antibiotics (-2.7%, p < 0.0001) and cardiovascular drug use (-3.8%, p < 0.0001), increase of analgesic use (+8.3%, p < 0.0001). Difficult working conditions, age and female gender were independently associated with analgesic drug use, and extraprofessional problems and female gender associated with psychotropic drug use.

CONCLUSIONS

This analysis of self-reported drug use in the working environment illustrates the global patterns of medication use in a French active population over 3 decades. The favorable development in the level of consumption of psychotropic drugs should not underestimate the attention to be paid to the determinants of chronic consumption, or possible transfers to less stigmatized medications.

Evaluation of Risk Factors Associated to Prescription of Benzodiazepines and its Patterns in a Cohort of Patients from Mental Health: A Real World Study in Spain

PURPOSE

we aimed 1) to evaluate the risk factors associated to the benzodiazepines intake; 2) to assess the impact about the use of long acting injectables antipsychotics (LAIs); 3) to assess the risk in severe and affective disorders and 4) to identify the prescription patterns of use in mental health in a cohort of patients from Spain.

METHODS

735 outpatients from Mental Health were included. Demographic and clinical data were collected. In order to compare the use of benzodiazepines we calculated the daily dose equivalents (mg/day) to diazepam as standard.

RESULTS

The most commonly prescribed benzodiazepine was clonazepam (33%) and the mean daily dose of diazepam equivalents was 24.9 mg. It was higher in affective disorders (40.35 ± 3.36) and lower in patients using LAIs antipsychotics (17.50 ± 1.39; p = 0.001). Multivariate analysis showed that to be women (OR = 1.559, 95% CI = 1.059-2.295, p = 0.024), the use of drugs (OR = 1.671, 95% CI = 1.127-2.477, p = 0.011) and suffering any affective disorder (OR = 1.542, 95% CI = 1.355-1.826, p = 0.040) increased the risk of benzodiazepine intake. In contrast, the use of LAIs antipsychotics significantly reduced it versus oral antipsychotics (OR = 5.226, 95% CI = 3.185-8.575, p = 0.001).

CONCLUSIONS

benzodiazepines are widely prescribed, mainly clonazepam followed by lorazepam and diazepam. Most of patients used at least one benzodiazepine and the mean daily intake was 25 mg diazepam equivalents. Therefore, benzodiazepines are extensively prescribed and used at higher doses than desirable. These, findings could be useful for clinicians and their practice.

Add-on benzodiazepine treatment in patients with major depressive disorder - results from a European cross-sectional multicenter study

Since many patients with major depressive disorder (MDD) do not satisfactorily respond to initial antidepressant monotherapy, add-on treatment strategies with other psychiatric compounds are often established. The present European multicenter cross-sectional study comprising 1410 MDD in- and outpatients investigated the prescription pattern of benzodiazepines as add-on treatment in the psychopharmacotherapy of MDD. Analyses of variance, chi-squared tests, and logistic regression analyses were conducted to examine differences in socio-demographic, clinical, and treatment characteristics between benzodiazepine users and non-users. The prescription rate for adjunctive benzodiazepine treatment amounted to 31.35%. The most often administered benzodiazepines were lorazepam (11.13%), clonazepam (6.74%), and alprazolam (6.60%). Benzodiazepine users exhibited more severe depressive symptoms expressed by a higher mean Montgomery and Åsberg Depression Rating Scale total score at study entry (26.92 ± 11.07 vs 23.55 ± 11.23, p<.0001) and at the beginning of the current major depressive episode (35.74 ± 8.08 vs 33.31 ± 7.40, p<.0001). Furthermore, they were characterized by a higher proportion of patients receiving additional augmentation/combination medications with antidepressants (40.95% vs 24.28%, p<.0001), antipsychotics (41.63% vs 18.39%, p<.0001), and low-potency antipsychotics (10.18% vs 4.75%, p<.0001). Moreover, benzodiazepine prescription was associated with older age, unemployment, inpatient treatment, suicide risk, psychotic and melancholic features, comorbid panic disorder, agoraphobia, social phobia, and obsessive-compulsive disorder. Taken together, our findings indicate that benzodiazepine augmentation in MDD is first of all established in severe/difficult-to-treat conditions and serves as predictor for the use of additional augmentation/combination treatment strategies.

Simulation study to demonstrate biases created by diagnostic criteria of mental illnesses: major depressive episodes, dysthymia, and manic episodes

OBJECTIVES

Composite diagnostic criteria alone are likely to create and introduce biases into diagnoses that subsequently have poor relationships with input symptoms. This study aims to understand the relationships between the diagnoses and the input symptoms, as well as the magnitudes of biases created by diagnostic criteria and introduced into the diagnoses of mental illnesses with large disease burdens (major depressive episodes, dysthymic disorder, and manic episodes).

SETTINGS

General psychiatric care.

PARTICIPANTS

Without real-world data available to the public, 100 000 subjects were simulated and the input symptoms were assigned based on the assumed prevalence rates (0.05, 0.1, 0.3, 0.5 and 0.7) and correlations between symptoms (0, 0.1, 0.4, 0.7 and 0.9). The input symptoms were extracted from the diagnostic criteria. The diagnostic criteria were transformed into mathematical equations to demonstrate the sources of biases and convert the input symptoms into diagnoses.

PRIMARY AND SECONDARY OUTCOMES

The relationships between the input symptoms and diagnoses were interpreted using forward stepwise linear regressions. Biases due to data censoring or categorisation introduced into the intermediate variables, and the three diagnoses were measured.

RESULTS

The prevalence rates of the diagnoses were lower than those of the input symptoms and proportional to the assumed prevalence rates and the correlations between the input symptoms. Certain input or bias variables consistently explained the diagnoses better than the others. Except for 0 correlations and 0.7 prevalence rates of the input symptoms for the diagnosis of dysthymic disorder, the input symptoms could not fully explain the diagnoses.

CONCLUSIONS

There are biases created due to composite diagnostic criteria and introduced into the diagnoses. The design of the diagnostic criteria determines the prevalence of the diagnoses and the relationships between the input symptoms, the diagnoses, and the biases. The importance of the input symptoms has been distorted largely by the diagnostic criteria.

Benzodiazepine use in Sao Paulo, Brazil

OBJECTIVES

To report the prevalence and factors associated with the use of benzodiazepines in the general population and those with a mental health condition in the metropolitan area of São Paulo, Brazil.

METHODS

5,037 individuals from the Sao Paulo Megacity Mental Health Survey data were interviewed using the Composite International Diagnostic Interview, designed to generate DSM-IV diagnoses. Additionally, participants were asked if they had taken any medication in the previous 12 months for the treatment of any mental health condition.

RESULTS

The prevalence of benzodiazepine use ranged from 3.6% in the general population to 7.8% among subjects with a mental health condition. Benzodiazepine use was more prevalent in subjects that had been diagnosed with a mood disorder as opposed to an anxiety disorder (14.7% vs. 8.1%, respectively). Subjects that had been diagnosed with a panic disorder (33.7%) or bipolar I/II (23.3%) reported the highest use. Individuals aged ≥50 years (11.1%), those with two or more disorders (11.2%), those with moderate or severe disorders (10%), and those that used psychiatric services (29.8%) also reported higher use.

CONCLUSION

These findings give an overview of the use of benzodiazepines in the general population, which will be useful in the public health domain. Benzodiazepine use was higher in those with a mental health condition, with people that had a mood disorder being the most vulnerable. Furthermore, females and the elderly had high benzodiazepine use, so careful management in these groups is required.

Perceptions, clinical characteristics, and other factors associated with prolonged and high daily dose of benzodiazepine use among patients with anxiety or depressive disorders

BACKGROUND

Benzodiazepines (BZDs) have been widely used to treat anxiety; however, the risk of adverse health effects caused by their long-term use is high. This study examined the factors associated with the duration and higher daily dose of BZDs use among a population with anxiety or depressive disorders.

METHODS

A cross-sectional study design was used. Patients from a psychiatric outpatient department who had been prescribed BZDs were recruited. Data were collected from 250 patients.

RESULTS

Nearly 94% of patients were long-term BZDs users. The mean duration of BZDs use was 5.5 years; and mean defined daily dose (DDD) of BZDs use, converted to diazepam milligram equivalent (DDD), was 1.53 DME-DDD. Patients who knew more about alternative treatments were less prone to use BZD longer. Patients aged 65 years or older and those with difficulty falling asleep were more prone to use BZDs longer. Patients who were currently taking BZDs at higher daily dose were those who felt more depressed, prescribed second generation antipsychotics, suffered from disrupted sleep, less aware of alternative treatments, had comorbid chronic physical illness, and were current smokers.

LIMITATIONS

The cross-sectional study design limited its ability to confirm causal relationships.

CONCLUSIONS

Long-term and excessive daily dose of BZDs use in patients with depressive or anxiety disorders needs to be noted. Providing information or program of non-pharmacological treatment in reducing anxiety and improving specific sleep disturbance is suggested. Elderly, suffering from depressive mood, had comorbid chronic physical illness need to be targeted for further intervention.

Trends in the consumption rates of benzodiazepines and benzodiazepine-related drugs in the health region of Lleida from 2002 to 2015

Background

The high prevalence and long-term use of benzodiazepines (BZDs) treatment are debated topics because of the risk they can cause to the patients. Despite the current information on the risk-benefit balance of these drugs, their consumption remains particularly high. We determined the trend in the consumption prevalence of benzodiazepines (BZDs) and drugs related to BZDs (Z-drugs) in the population of the Health Region of Lleida to explore patterns of use and the associated characteristics associated between 2002 and 2015.

Methods

An analysis of secular trends was carried out between 2002 and 2015; the databased included all individuals from the Health Region of Lleida, which had 358,157 inhabitants in 2015, that consumed BZDs. The consumption of BZDs was evaluated using prescription billing data from the Public Health System. All types of BZDs and BZD analogues that had been approved by the drug agency were included. Trends by age and sex were investigated.

Results

Over the whole study period, a total of 161,125 individuals accounted for 338,148 dispensations. Overall, 59% were women, and the mean age was 56 years. The dispensing prevalence of BZDs use in 2015 was 14.2% overall —18.8% in women and 9.6% in men—and was 36% in those over 65 years. According to the half-life of BZDs, the prevalence of short-intermediate BZD use, intermediate-long BZD use, and Z-drugs use was 9.7, 5.5 and 0.8%, respectively. The evolution of the annual prevalence of BZD dispensing showed a progressive decline, from 15.3% in 2002 to 14.2% in 2015, which was attributed to a decrease in the consumption of intermediate-long half-life BZDs (8.0% vs. 5.5%) and Z-drugs (1.4% vs. 0.8%).

Conclusion

The dispensing prevalence of BZDs and Z-drugs was high, although a small reduction was observed during this time period. The dispensing prevalence was especially high in the population over 65, despite the risk of cognitive decline and falls. Integral actions are required to lower the BZD prescription rate.

How did the use of psychotropic drugs change during the Great Recession in Portugal? A follow-up to the National Mental Health Survey

BACKGROUND

Research suggests that economic recessions might be associated with a higher use of psychotropic drugs, but literature is scarce and contradictory in identifying the most vulnerable groups. This study aims to assess possible changes in the use of psychotropic drugs due to the economic recession in Portugal, by comparing self-reported consumption in 2008/09 and 2015/16.

METHODS

Data from the World Mental Health Survey Initiative Portugal (2008/09) and the National Mental Health Survey Follow-Up (2015/16) were used (n = 911). McNemar's tests were performed to estimate changes in consumption of any psychotropic drug and of antidepressants, anxiolytics, and hypnotics/sedatives. Multiple Generalised Estimating Equations models with interaction effects were used to estimate the population odds of consuming psychotropic drugs according to year, gender and age.

RESULTS

An increase of 6.74% was estimated in the consumption of psychotropic drugs from 2008/09 to 2015/16. Population odds of consuming any psychotropic drugs in 2015/16 were estimated to be 1.5 times higher than in 2008/09 (OR = 1.50;95%CI:1.13-2.01), particularly for hypnotics/sedatives (OR = 1.60;95%CI:1.14-2.25). Women and older individuals presented higher odds of consuming any psychotropic drugs (OR = 2.79;95%CI:2.03-3.84, and OR = 1.80;95%CI:1.28-2.54), after adjusting for year of assessment and education. However, when evaluating the interaction effect of the year with gender and age, men and younger individuals reported higher odds of consuming any psychotropic drugs in 2015/16, when compared to 2008/09 (OR = 1.85;95%CI:1.08-3.17, and OR = 1.95;95%CI:1.32-2.90, respectively).

CONCLUSIONS

The findings indicate that the period of economic recession was associated with an increased risk of psychotropic drugs use in Portugal. Consumption of psychotropic drugs remained higher among women and older individuals, but the results suggest that the economic crisis had a disproportionate impact on men and younger individuals. This identification of the most vulnerable population groups is useful to design effective and targeted public health interventions aimed at alleviating the effects of economic recessions.

Comparison of psychotropic medication use in the Baltic countries

Purpose: While the pivotal role of pharmacotherapy in psychiatry is universal, significant regional differences exist in drug use patterns. Herewith we compare the use of ATC psychotropic drugs (N05, psycholeptics and N06A, antidepressants) in 2010-2015 in the three Baltic Countries with reference to the Nordic Countries.Methods: Data were obtained from the national authorities on medicines as expressed in DDD per 1000 inhabitants per day. A semi-structured questionnaire was used for expert statements on the rationale of current use of medicines.Results: During the observation period the use of antipsychotics, anxiolytics, hypnotics and sedatives, and antidepressants steadily increased, while the growth in use of anxiolytics stagnated in the more recent years. Antipsychotic use was the largest in Lithuania and the lowest in Estonia. The use on anxiolytics in Lithuania was more than twice of that in Estonia and Latvia. Conversely, the use of hypnotics and sedatives was about three times higher in Estonia than in Latvia or Lithuania. Antidepressant use was dominated by the selective serotonin reuptake inhibitors in all three countries, but overall was much lower in Latvia as compared to Lithuania and Estonia. As compared to the Nordic Countries in 2015, antidepressants are used at much lower level throughout Baltics, probably reflecting underdiagnostics of depression and anxiety disorders.Conclusion: While the health-care expenditures in Estonia, Latvia and Lithuania are largely similar, as is the cultural and recent political background of these EU member countries, the extent and the pattern of psychotropic drug use is remarkably variable.

Use of benzodiazepines and z-drugs not compliant with guidelines and associated factors: a population-based study

Benzodiazepines and z-drugs are primarily indicated for the treatment of sleep disorders and anxiety symptoms. Their frequent long-term use contrasts with the international guidelines that limit treatment duration to a maximum of 4 weeks. The objective of this study was to assess the frequency of their use that was not in accordance with guidelines in the French general population between 2007 and 2012 and associated characteristics. A cohort of 67,550 benzodiazepine new users was set up in an exhaustive database for health-care reimbursements and representative of the French population. Benzodiazepine use not in accordance with guidelines was defined as the concomitant dispensation of several benzodiazepines, the dispensation of treatment over a period longer than recommended, or a new dispensing within the 2 months following the end of a previous treatment of maximum recommended duration, considering that French recommendations distinguish between hypnotic (4 weeks) and anxiolytic benzodiazepines (12 weeks). Benzodiazepine use not in accordance with guidelines was high, in about 30% of new hypnotic users and 20% of new anxiolytic users. Its frequency was stable over the study period. Associated characteristics were similar for new hypnotic or anxiolytic users, i.e.. older age, treatment initiation by a psychiatrist, presence of a chronic disease, hospitalization, or another psychotropic treatment. These findings provide a solid basis for establishing a public health policy to reduce benzodiazepine use not compliant with guidelines. They should be further explored in patients most at risk in the present study, e.g., patients treated by a psychiatrist.

A Durable Minimal Intervention Strategy to Reduce Benzodiazepine Use in a Primary Care Population

Background

Benzodiazepines are commonly prescribed drugs with approximately 10% of adults having used them in the past year. These drugs are clearly addictive, yet many patients are prescribed these for years, with long-term side effects. The present study aimed to investigate whether patients on repeat diazepam prescription had their prescription reviewed to reduce and to stop the repeat prescription wherever appropriate, and whether these changes were sustained at 24 months.

Methods

The present study used a minimal intervention strategy to reduce diazepam use in a semi-rural general practice. Patients with a current prescription for diazepam were invited to visit their general practitioner for a review. Dose reduction grids were formulated for each individual to facilitate a downward titration by 1 mg each wk/mo. Patients with psychiatric co-morbidity were also included. Interrupted time series methods were applied to the monthly data. The outcomes were evaluated at 12 and 24 months.

Results

Ninety-two patients had diazepam on repeat prescription with 87 (94.6%) attending the review appointment. Twenty-seven patients (29.3%) were under psychiatric review and were supported by the psychiatrist with a downward titration regime. At 24 months, 63 patients (81.8% of the 77 still at the practice) had stopped or were in the process of stopping regular use of diazepam. A statistically significant reduction in total monthly diazepam prescription was observed (from 2.2 to 0.7 defined daily dose/1,000 patients/d).

Conclusion

This minimal intervention strategy, in collaboration between primary and secondary care, produced a durable reduction in overall diazepam prescription at the general practice.

Prevalence of prescribed benzodiazepine long-term use in the French general population according to sociodemographic and clinical factors: findings from the CONSTANCES cohort

Background

Data are lacking regarding the prevalence of benzodiazepine long-term use in the general population. Our aim was to examine the prevalence of prescribed benzodiazepine long-term use (BLTU) according to sociodemographic and clinical factors in the French general population.

Methods

Data came from 4686 men and 4849 women included in 2015 in the French population-based CONSTANCES cohort. BLTU was examined using drug reimbursement administrative registries from 2009 to 2015. Analyses were weighted to provide results representative of the French general population covered by the general health insurance scheme. Weighted prevalence of BTLU and weighted Odds Ratios (OR) of having BTLU were computed with their 95% Confidence Interval (95% CI) according to age, education level, occupational status, occupational grade, household income, marital status, alcohol use disorder risk and depressive symptoms. All the analyses were stratified for gender.

Results

Weighted prevalence of BLTU were 2.8%(95% CI:2.3–3.4) and 3.8%(95% CI: 3.3–4.5) in men and women, respectively. Compared to men, women had an increased risk of having benzodiazepine long-term use with OR = 1.34(95% CI = 1.02–1.76). Aging, low education, not being at-work, low occupational grade, low income, being alone and depressive state were associated with increased risks of having BTLU.

Conclusions

BLTU is widespread in the French general population, however this issue may particularly concern vulnerable subgroups. These findings may help in raising attention on this public health burden as well as targeting specific at-risk subgroups in preventive intervention.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6933-8) contains supplementary material, which is available to authorized users.

Antidepressant treatment among social workers, human service professionals, and non-human service professionals: A multi-cohort study in Finland, Sweden and Denmark

BACKGROUND

Social workers have an elevated risk for mental disorders, but little is known about their antidepressant treatment.

AIMS

To examine any and long-term antidepressant treatment among social workers in Finland, Sweden and Denmark.

METHODS

We linked records from drug prescription registers to three prospective cohorts: the Finnish Public Sector study, years 2006-2011, and nation-wide cohorts in Sweden and Denmark, years 2006-2014, including a total of 1.5 million employees in (1) social work, (2) other social and health care professions, (3) education and (4) office work. We used Cox proportional hazards models to estimate hazard ratios for any and long-term (>6 months) antidepressant treatment among social workers compared to the three reference occupational groups and carried out meta-analyses.

RESULTS

During follow-up, 25% of social workers had any prescriptions for antidepressants (19-24% reference occupations) and 20% for long-term treatment (14-19% reference occupations). The pooled effects for any and long-term treatment showed that probabilities were 10% higher in social workers compared to other health and social care professionals and 30% higher compared to education and non-human service professionals. Probabilities for any treatment in the three countries were relatively similar, but for long-term treatment social workers in Finland had a greater risk compared with other human service professions.

LIMITATIONS

There were differences between the cohorts in the availability of data. Specific diagnoses for the antidepressant treatment were not known neither adherence to treatment.

CONCLUSION

Social workers have a higher risk for any and long-term antidepressant treatment than other human and non-human service professionals.

Exploring characteristics associated with first benzodiazepine prescription in patients with affective disorders and related diagnoses

OBJECTIVE

In patients with affective disorders, benzodiazepines (BZDs) are frequently administered at the onset, sometimes inappropriately. We sought to identify clinical variables associated with first BZD prescription in a large sample of patients with affective disorders.

METHODS

Four hundred sixty patients with mood or anxiety disorders attending different psychiatric services were assessed comparing those who received BZD as first treatment (BZD w/) and those who did not (BZD w/o).

RESULTS

More than one third (35.7%) of the total sample had received BZDs as first prescription. In relation to mood disorders, BZD w/ subjects more frequently (a) had not a psychiatrist as first therapist, (b) had anxious symptoms at onset, (c) had adjustment disorder as first diagnosis, (d) were treated as outpatients. In relation to specific diagnoses, (a) personal decision of treatment for major depressive disorder, (b) outpatient status for bipolar disorder and (c) longer duration of untreated illness for adjustment disorder were more frequently associated with first BZD prescription. For anxiety disorders, the presence of stressful life events and the diagnoses of panic disorder or specific phobias were more frequently observed in BZD w/ patients.

CONCLUSION

Patients with affective disorders frequently received BZDs as first prescription with significant differences between and within mood and anxiety disorders.

Study of antidepressant use in 5 European settings. Could economic, sociodemographic and cultural determinants be related to their use?

BACKGROUND

We aimed at describing the trends in antidepressants use (AD) by age and sex, during 2007-2011, in 5 European settings (Sweden, Norway, Denmark, Catalonia and Veneto), and to assess whether the differences found across settings could be related to economic, social and cultural determinants.

METHODS

We collected data of AD use expressed in defined daily doses (DDD). Data were retrieved from population-based databases. We calculated DDD/1000 inhabitants/day. We analysed which economic, social, and cultural covariates determined between-settings differences in AD consumption.

RESULTS

The use of AD showed an increasing trend during the study period, being Selective Serotonin Reuptake Inhibitors the most consumed, followed "others AD". Women and the elderly showed the highest AD consumption. Between-settings variability in AD consumption showed a positive correlation with pharmaceutical expenditure and a negative one with general practitioner's rate. After adjusting by pharmaceutical expenditure and general practitioners rate Masculinity, Long-Term Orientation and Individualism cultural dimensions were associated with AD use by using the Hofstede´s cultural dimensions model.

LIMITATIONS

This study has been conducted in administrative databases, with no information on AD use by indication; differences among AD use could be related to their prescription for other disorders. Analyses were based on a small dataset and none of the results reached statistical significance.

CONCLUSIONS

AD use increased through 2007-2011. Pharmaceutical expenditure and General Practitioners rate, Masculinity, Long-Term Orientation and Individualism explained the differences in AD use between countries. People's attitude should be considered when designing national campaigns to improve antidepressant use.

Effect of work schedule on prospective antidepressant prescriptions in Sweden: a 2-year sex-stratified analysis using national drug registry data

INTRODUCTION

Depression-related mood disorders affect millions of people worldwide and contribute to substantial morbidity and disability, yet little is known about the effects of work scheduling on depression. This study used a large Swedish survey to prospectively examine the effects of work schedule on registry-based antidepressant prescriptions in females and males over a 2-year period.

METHODS

The study was based on an approximately representative sample (n=3980 males, 4663 females) of gainfully employed participants in the Swedish Longitudinal Occupational Survey of Health. Sex-stratified analyses were conducted using logistic regression. For exposure, eight categories described work schedule in 2008: 'regular days' (three categories of night work history: none, ≤3 years, 4+ years), 'night shift work', 'regular shift work (no nights)', 'rostered work (no nights)', 'flexible/non-regulated hours' and 'other'. For the primary outcome measure, all prescriptions coded N06A according to the Anatomical Therapeutic Chemical System were obtained from the Swedish National Prescribed Drug Register and dichotomised into 'any' or 'no' prescriptions between 2008 and 2010. Estimates were adjusted for potential sociodemographic, health and work confounders, and for prior depressive symptoms.

RESULTS

In 2008, 22% of females versus 19% of males worked outside of regular daytime schedule. Registered antidepressant prescription rates in the postsurvey period were 11.4% for females versus 5.8% for males. In fully adjusted models, females in 'flexible/non-regulated' schedules showed an increased OR for prospective antidepressant prescriptions (OR=2.01, 95% CI=1.08 to 3.76). In males, odds ratios were most increased in those working 'other' schedules (OR=1.72, 95% CI=0.75 to 3.94) and 'Regular days with four or more years' history of night work' (OR=1.54, 95% CI=0.93 to 2.56).

CONCLUSIONS

This study's findings support a relationship between work schedule and prospective antidepressant prescriptions in the Swedish workforce. Future research should continue to assess sex-stratified relationships, using detailed shift work exposure categories and objective registry data where possible.

The Association Between the Sedative Loads and Clinical Severity Indicators in the First-Onset Major Depressive Disorder

Background: High sedative use in a major depressive episode may imply specific clinical features. This study aims to examine the correlation between sedative use and clinical severity indicators in the initial treatment phase of first-onset major depressive disorder. Methods: A study cohort in the first episode of major depressive disorder was used to conduct pharmacological dissection. All participants had at least a 2-year follow-up period with a complete treatment record. The defined daily dose of antidepressants and augmentation agents were calculated as the antidepressant load and augmentation load, respectively. Sedative use, which was calculated as the equivalent dosage of lorazepam, were defined as the sedative load. These psychotropic loads were measured monthly and the averaged psychotropic loads for each day were obtained. Results: A total of 106 individuals (75.5% female) were included. The mean duration of disease course in participants was 5.5 ± 3.5 years. In the multiple regression analysis, after controlling for other classes of psychotropics and comorbid anxiety disorders, the sedative load independently correlated with higher number of antidepressants used, higher number of antidepressant used with an adequate dose and duration, more psychiatric emergency and outpatient visits within 2 years of disease onset. Conclusion: High loading of sedatives correlated with several indicators of clinical severity in major depressive disorder. The sedative load may be used as a specifier to identify subgroups in patients with major depressive disorder.

Prevalence and Factors Associated With Psychiatric Medication Use in Bariatric Surgery Candidates

OBJECTIVE

We aimed to describe the rates of psychiatric medication use in bariatric surgery candidates and factors associated with psychiatric medication use.

METHODS

Patients from the Toronto Western Hospital Bariatric Surgery Program were recruited from 2011 to 2014. Data extracted included demographics, clinical factors (e.g., mood disorder, anxiety disorder, eating disorder, Patient Health Questionnaire-9, Generalized Anxiety Disorder 7), and psychiatric medication use. Logistic regression analyses were used to examine the relationship between demographic variables, clinical factors, and psychiatric medication use. Multiple logistic regression was conducted to determine the predictors of clinical factors from demographic variables with psychiatric medication use.

RESULTS

A total of 262 (35.1%) patients were taking at least 1 psychiatric medication and 105 patients (14.1%) were taking more than 1 psychiatric medication. Antidepressants were the most common psychiatric medication reported. The majority of patients taking a psychiatric medication had a psychiatric illness, with 16.0% not having a lifetime diagnosis of a mental illness. Being male and being employed significantly predicted lower odds of being on a psychiatric medication. Older age significantly predicted higher odds of being on a psychiatric medication. Psychiatric disorders were significantly associated with psychiatric medication use independent of demographic variables.

CONCLUSION

Our study provides insights into clinical and demographic factors related to psychiatric medication use in bariatric surgery patients. The findings support careful screening and clarification of psychiatric medications, especially in patients without a formal psychiatric diagnosis.

[The use of prescription drugs with dependence potential in Germany : A prospective analysis of prescriptions in the public healthcare system between 2006 and 2010]

BACKGROUND

In Germany, about 1.4 to 2.6 million people are dependent on prescription drugs, mainly benzodiazepine derivatives and opioid analgesics. Despite this large number of affected people, studies on prescription behaviour and drug intake are scarce. There are particularly few empirical findings available with regard to elderly people age 65 and over who are disproportionally affected by prescription drug abuse.

METHODS

The North German Pharmacy Computing Centre (Norddeutsches Apothekenrechenzentrum, NARZ) collects the prescription data of about 11 million citizens and covers over 80% of drug pharmacies in North Germany. Based on the data from NARZ, we evaluate person-related prescriptions of benzodiazepines, Z‑drugs and opioid analgesics. By means of incremental calculations, we determine the prevalence of prescription drug use, the long-term intake, the average daily dose of these medications and present this information as a five-year trend (2006-2010).

RESULTS

In 2006, 10.6% of the members of public healthcare system were prescribed at least one of the medications under study. This proportion hardly changed within the five-year span. The share of patients with benzodiazepine prescription steadily decreased from 2006 (5.5%) to 2010 (5.1%), especially among elderly people. While the prevalence of Z‑drug prescriptions remained the same at about 1%, there was a slight increase in prescriptions of opioid analgesics with 5.4% in 2006 to 5.7% in 2010. The proportion of patients with long-term prescriptions decreased with regard to benzodiazepines (from 17.0 to 12.8%) and Z‑drugs (from 24.3 to 21.2%), but increased for opioid analgesics (from 19.2 to 21.2%).

CONCLUSION

The analytical method used in this study is an innovative epidemiological approach to evaluate person-related register data over the course of several years. Establishing a monitoring system of prescription drugs with potential for dependence may allow for a quicker identification of trends and initiation of appropriate measures.

Patterns of benzodiazepines use in primary care adults with anxiety disorders

BACKGROUND

Benzodiazepines are among the most commonly prescribed drugs for anxiety disorders. While they are indicated as adjunctive treatment for short-term use according to clinical practice guidelines, previous studies have shown patterns of long-term use of benzodiazepines, which is problematic due to side effects, dependence and potential of abuse. The aims of this study were to examine among a large sample of primary care adults suffering from anxiety disorders: 1) benzodiazepine use patterns; and 2) correlates of long-term benzodiazepine use.

METHODS

Data were drawn from the "Dialogue" project, a large primary care study conducted in 64 primary care clinics in the province of Quebec, Canada. Following a mental health screening in waiting rooms, patients at risk of anxiety or depression completed the Composite International Diagnostic Interview-Simplified (CIDIS). A sample of 740 adults meeting DSM-IV criteria for Generalized Anxiety Disorder, Panic Disorder or Social Anxiety Disorder in the past 12 months took part in this study.

RESULTS

Benzodiazepines were used by 22.6% of participants with anxiety disorders in our primary care sample. A large majority of benzodiazepine users (88.4%) met our indicator of long-term use, as defined by utilization for more than 12 weeks including regular and as-needed use. Based on a logistic regression model, individual correlates associated with long-term benzodiazepine use included: being 30 years or older, having a comorbid physical illness, meeting criteria for comorbid agoraphobia, reporting the use of sleep-aids, and concurrent SSRI utilization.

LIMITATION

Data collection with self-reported questionnaires may be subject to information bias.

CONCLUSIONS

Despite knowledge of the risks of long-term use of benzodiazepines, this remains a pervasive problem. Clinicians need to be mindful of patterns and risk factors leading to long-term use of benzodiazepines in patients with anxiety disorders. Results of this study should raise awareness regarding appropriate prescription practices for benzodiazepines, including decision-making in initiation, duration of prescription, and use of strategies for discontinuation in current long-term benzodiazepine users.

Predictors of antidepressant use in the English population: analysis of the Adult Psychiatric Morbidity Survey

Objectives

The rate of antidepressant use in the United Kingdom has outpaced diagnostic increases in the prevalence of depression. Research has suggested that personal and socioeconomic risk factors may be contributing to antidepressant use. To date, few studies have addressed these possible contributions. Thus, this study aimed to assess the relative strength of personal, socioeconomic and trauma-related risk factors in predicting antidepressant use.

Methods

Data were derived from the Adult Psychiatric Morbidity Survey (n=7403), a nationally representative household sample of adults residing in England in 2007. A multivariate binary logistic regression model was developed to assess the associations between personal, socioeconomic and trauma-related risk factors and current antidepressant use.

Results

The strongest predictor of current antidepressant use was meeting the criteria for an ICD-10 depressive episode [odds ratio (OR)=9.04]. Other significant predictors of antidepressant use in this analysis included English as first language (OR=3.45), female gender (OR=1.98), unemployment (OR=1.82) and childhood sexual abuse (OR=1.53).

Conclusions

Several personal, socioeconomic and trauma-related factors significantly contributed to antidepressant use in the multivariate model specified. These findings aid our understanding of the broader context of antidepressant use in the United Kingdom.

Long-term benzodiazepine use in patients taking antidepressants in a public health setting in Brazil: a cross-sectional study

OBJECTIVE

The aims of the study were to investigate the prevalence of long-term use of benzodiazepines in patients taking antidepressants and to identify the risk factors associated with the prolonged use of benzodiazepines.

DESIGN

Cross-sectional study.

SETTING

Public health system in Brazil.

PARTICIPANTS

Outpatients using antidepressants from January 2008 to December 2009 were included. The data were obtained from pharmacy databases and medical records. All individuals in the database were included in the study and were classified into two categories: (1) patients who had not used benzodiazepines combined with antidepressants or had combined the use of antidepressants with benzodiazepines for a short period (up to 4 weeks), and (2) those who used antidepressants plus benzodiazepines for a longer period (more than 4 weeks).

MAIN OUTCOME MEASURE

The outcome measure is prolonged use of benzodiazepines (more than 4 weeks). We conducted a multivariate analysis to identify the factors associated with prolonged use of benzodiazepines.

RESULTS

Forty per cent of the 870 patients evaluated had prolonged use of benzodiazepines (more than 4 weeks). The risk factors associated with prolonged use were age above 35 years (prevalence ratio (PR): 2.18, 95% CI 1.55 to 3.06, P<0.001), female sex (PR: 1.47, 95% CI 1.07 to 2.02, P=0.019), diagnosis at least 3 years prior (PR: 2.1, 95% CI 1.6 to 2.8, P<0.001), use of selective serotonin reuptake inhibitor antidepressants (PR: 1.7, 95% CI 1.3 to 2.2, P<0.001) and having a prescription from a psychiatrist (PR: 6.5, 95% CI 3.2 to 13.2, P<0.001).

CONCLUSIONS

Prolonged use of benzodiazepines occurs more frequently in women, adults diagnosed several years earlier, users of selective serotonin reuptake inhibitor antidepressants and those who received a prescription from a psychiatrist. Education of clinicians, especially with regard to these populations, may decrease the overuse and misuse of benzodiazepines.

Predictors of benzodiazepine use in a transdiagnostic sample of panic disorder, social anxiety disorder, and obsessive-compulsive disorder patients

We investigated the rates of current and past benzodiazepine (BZD) use in a sample of 102 subjects attending specialized anxiety disorder clinics, including panic disorder (PD; N = 36), social anxiety disorder (SAD; N = 28) and obsessive-compulsive disorder (OCD; N = 38) patients. Almost 56% of the entire sample was using BZDs at the moment of the assessment, and 74.5% described having used them at some point during their lifetimes. The duration of psychiatric treatment and a lifetime history of PD, but not any other "transdiagnostic" measure of severity (such as the Panic and Agoraphobia Scale, the Social Phobia Inventory, the Dimensional Obsessive-Compulsive Scale, the Anxiety Sensitivity Index-36, and the Beck Inventories) were independent risk factors for current prescription of BZDs. Patients who continued to use BZDs differed from patients who stopped them by being older (both currently and when firstly seen in the clinic), by having a later age at onset of their most significant anxiety disorder, by being more agoraphobic/avoidant, and by believing to be less capable of stopping their BZDs for the fear of not being able to sleep.

Benzodiazepines for anxiety disorders: maximising the benefits and minimising the risks

Benzodiazepines still play an important role in the management of anxiety disorders but dependence is associated with their therapeutic use. The key to effective and safe long-term use of benzodiazepines is: the careful selection of patients who might benefit from them; administration in clinical situations in which they are more likely to be beneficial; use of lower doses and in conjunction with an antidepressant, if possible; monitoring and managing their side-effects; and minimising the risk of withdrawal symptoms and relapse, mainly through tapering the dose and/or combining with effective psychological interventions.

Antidepressant use and associated factors among the elderly: the Bambuí Project

This study examined the factors associated with antidepressant use among community-dwelling elderly individuals. Data collected from the Bambuí Project, a population-based study on aging and health with a cohort of 1,606 elderly individuals, were used. Gender, age, education, marital status, household income and cohabitation status were the sociodemographic characteristics investigated. Health conditions included self-reported health, number of chronic diseases, depressive symptoms, cognitive impairment and functional disability. Poisson regression with robust variance was used to test associations and to estimate prevalence ratios with 95% confidence intervals. The prevalence of antidepressant use was 8.4%. After multivariate analysis, antidepressant use was associated with the female gender (PR = 2.96; 95%CI 1.82-4.81), being single or divorced (PR = 0.48; 95%CI 0.25-0.91), cognitive impairment (PR = 0.44; 95%CI 0.24-0.84) and worse self-reported health (poor/very poor) (PR=1.86; 95%CI 1.11-3.10). The results are similar to those observed in several other studies conducted in higher-income countries and suggest that self-reported health in the elderly population of Bambuí is a key factor in the decision to use antidepressants.

Simultaneous Antidepressant and Benzodiazepine New Use and Subsequent Long-term Benzodiazepine Use in Adults With Depression, United States, 2001-2014

IMPORTANCE

Benzodiazepines have been prescribed for short periods to patients with depression who are beginning antidepressant therapy to improve depressive symptoms more quickly, mitigate concomitant anxiety, and improve antidepressant treatment continuation. However, benzodiazepine therapy is associated with risks, including dependency, which may take only a few weeks to develop.

OBJECTIVES

To examine trends in simultaneous benzodiazepine and antidepressant new use among adults with depression initiating an antidepressant, assess antidepressant treatment length by simultaneous new use status, estimate subsequent long-term benzodiazepine use in those with simultaneous antidepressant and benzodiazepine new use, and identify determinants of simultaneous new use and long-term benzodiazepine use.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study using a US commercial claims database included commercially insured adults (aged 18-64 years) from January 1, 2001, through December 31, 2014, with a recent depression diagnosis who began antidepressant therapy but had not used antidepressants or benzodiazepines in the prior year.

EXPOSURES

Simultaneous new use, defined as a new benzodiazepine prescription dispensed on the same day as a new antidepressant prescription.

MAIN OUTCOMES AND MEASURES

The proportion of antidepressant initiators with simultaneous new use and continuing antidepressant treatment for 6 months and the proportion of simultaneous new users receiving long-term (6-months) benzodiazepine therapy.

RESULTS

Of the 765 130 adults (median age, 39 years; interquartile range, 29-49 years; 507 451 women [66.3%]) who initiated antidepressant treatment, 81 020 (10.6%) also initiated benzodiazepine treatment. The mean annual increase in the proportion simultaneously starting use of both agents from 2001 to 2014 was 0.49% (95% CI, 0.47%-0.51%), increasing from 6.1% (95% CI, 5.5%-6.6%) in 2001 to 12.5% (95% CI, 12.3%-12.7%) in 2012 and stabilizing through 2014 (11.3%; 95% CI, 11.1%-11.5%). Similar findings were apparent by age group and physician type. Antidepressant treatment length was similar in simultaneous new users and non-simultaneous new users. Among simultaneous new users, 12.3% (95% CI, 12.0%-12.5%) exhibited long-term benzodiazepine use (64.0% discontinued taking benzodiazepines after the initial fill). Determinants of long-term benzodiazepine use after simultaneous new use were longer initial benzodiazepine days' supply, first prescription for a long-acting benzodiazepine, and recent prescription opioid fills.

CONCLUSIONS AND RELEVANCE

One-tenth of antidepressant initiators with depression simultaneously initiated benzodiazepine therapy. No meaningful difference in antidepressant treatment at 6 months was observed by simultaneous new use status. Because of the risks associated with benzodiazepines, simultaneous new use at antidepressant initiation and the benzodiazepine regimen itself require careful consideration.

Socio-demographic factors and long-term use of benzodiazepines in patients with depression, anxiety or insomnia

Former studies that have attempted to characterize individual socio-demographic factors associated with long-term benzodiazepine use were based on relatively small sample sizes and/or self-reported data. Our aim was to clarify this using large-scale primary health care data from Sweden. The present study covered 71 primary health care centres containing individual-level data from a total of 919, 941 individuals who visited a primary health care centre (PHCC) during the period 2001-2007. From this database we selected individuals 25 years or older with depression, anxiety and/or insomnia and who were prescribed a benzodiazepine within 0-90 as well as 91-270 days after their first clinical diagnosis of depression, anxiety and/or insomnia. Older age (OR, 2.92, 95% CI, 2.28-3.84), middle SES (OR, 1.22, 95% CI, 1.08-1.38), being on social welfare (OR, 1.40, 95% CI, 1.23-1.62) and not being married were associated with higher long-term benzodiazepine use. The PHCCs only explained a small part of the individual variation in long-term benzodiazepine use. Awareness of the impact on long-term benzodiazepine use of certain individual-level socio-demographic factors is important for health care workers and decision-makers who should aim at targeting general interventions at all primary health care centres.

Pregabalin for the Treatment of Drug and Alcohol Withdrawal Symptoms: A Comprehensive Review

Treatments for physical dependence and associated withdrawal symptoms following the abrupt discontinuation of prescription drugs (such as opioids and benzodiazepines), nicotine, alcohol, and cannabinoids are available, but there is still a need for new and more effective therapies. This review examines evidence supporting the potential use of pregabalin, an α2δ voltage-gated calcium channel subunit ligand, for the treatment of physical dependence and associated withdrawal symptoms. A literature search of the MEDLINE and Cochrane Library databases up to and including 11 December 2015 was conducted. The search term used was '(dependence OR withdrawal) AND pregabalin'. No other date limits were set and no language restrictions were applied. Works cited in identified articles were cross-referenced and personal archives of references also searched. Articles were included based on the expert opinions of the authors. There is limited evidence supporting the role of pregabalin for the treatment of physical dependence and accompanying withdrawal symptoms associated with opioids, benzodiazepines, nicotine, cannabinoids, and alcohol, although data from randomized controlled studies are sparse. However, the current evidence is promising and provides a platform for future studies, including appropriate randomized, placebo- and/or comparator-controlled studies, to further explore the efficacy and safety of pregabalin for the treatment of withdrawal symptoms. Given the potential for pregabalin misuse or abuse, particularly in individuals with a previous history of substance abuse, clinicians should exercise caution when using pregabalin in this patient population.

Psychotropic drug use and alcohol consumption among older adults in Germany: results of the German Health Interview and Examination Survey for Adults 2008-2011

OBJECTIVES

The use and combined use of psychotropic drugs and alcohol among older adults is a growing public health concern and should be constantly monitored. Relevant studies are scarce in Germany. Using data of the most recent national health survey, we analyse prevalence and correlates of psychotropic drug and alcohol use among this population.

METHODS

Study participants were people aged 60-79 years (N=2508) of the German Health Interview and Examination Survey for Adults 2008-2011. Medicines used during the last 7 days were documented. Psychotropic drugs were defined as medicines acting on the nervous system (ATC code N00) excluding anaesthetics (N01), analgesics/antipyretics (N02B), but including opiate codeines used as antitussives (R05D). Alcohol consumption in the preceding 12 months was measured by frequency (drinking any alcohol-containing beverages at least once a week/a day) and quantity (alcohol consumed in grams/day; cut-offs: 10/20 g/day for women/men defining moderate and risky drinking). SPSS complex sample module was used for analysis.

RESULTS

21.4% of study participants use psychotropic medications, 66.9% consume alcohol moderately and 17.0% riskily, 51.0% drink alcohol at least once a week and 18.4% daily, 2.8% use psychotropic drugs combined with daily alcohol drinking. Among psychotropic drug users, 62.7% consume alcohol moderately, 14.2% riskily. The most frequently used psychotropic medications are antidepressants (7.9%) and antidementia (4.2%). Factors associated with a higher rate of psychotropic drug use are female sex, worse health status, certified disability and polypharmacy. Risky alcohol consumption is positively associated with male sex, smoking, upper social class, better health status, having no disability and not living alone.

CONCLUSIONS

Despite the high risk of synergetic effects of psychotropic drugs and alcohol, a substantial part of older psychotropic drug users consume alcohol riskily and daily. Health professionals should talk about the additional health risks of alcohol consumption when prescribing psychotropic drugs to older adults.

[Determining factors for the use of anxiolytic and hypnotic drugs in the elderly]

INTRODUCTION

To estimate the prevalence of self-reported anxiety/hypnotics use in adults 65 years and older and identify potential factors that determine the use of these drugs.

MATERIAL AND METHODS

Cross-sectional study conducted on a study population of 1,161 non-institutionalised adults 65 years old and older with enough ability to conduct a personal interview. Participants were randomly selected from health care registers. The main outcomes of interest included consumption of anxiolytics, hypnotics and other drugs (filed by ATC classification system), mood (based on the Yesavage geriatric depression scale), cognitive status (Pfeiffer questionnaire), physical-functional assessment of basic activities of daily living (Katz index), health problems (ICPC-2 classification WONCA), and sociodemographic variables.

RESULTS

The prevalence of self-reported anxiety/hypnotics consumption was 16.6% (95% CI: 14.5 - 18.7), of which 90.5% were benzodiazepines (BZD), mainly lorazepam (39.4% of BZD). Long half-life BZD accounted for 24.7% of BZD. Hypnotics accounted for 27.5% of anxiolytics/hypnotics. The use of sedatives/hypnotics was independently associated with other drugs (non-psychotropics) consumption (OR 6.8, 95% CI: 2.1-22.0), presence of established depression (OR: 2.5; 95% CI: 1.0 -5.9), presence of 4 or more comorbidities (OR: 2.0; 95% CI: 1.4-2.9), being female (OR 2.1, 95% CI: 1.5-3.1) and being dependent for basic activities of daily living (OR: 1.8, 95% CI: 1.1-2.9).

CONCLUSIONS

The prevalence of sedatives/hypnotics use in the elderly from Albacete is high. Several factors were identified as potential determinants of sedatives/hypnotics use in our study population. It will be important to evaluate the misuse of these drugs in order to develop effective, efficient and safe prescription strategies.

Prescription patterns of benzodiazepines in the Lebanese adult population: a cross-sectional study

This study assessed the profile of benzodiazepine (BDZ) users in Lebanon. Adult patients visiting the pharmacies with prescriptions of BDZs were included in the study. Seven hundred and eighty-six current BDZ users were included, of whom 54.2% were females. Twenty-three percent reported being alcohol consumers and were mostly males. The two most commonly used BDZs were alprazolam (34.6%) and bromazepam (33.6%). The indication for use was mainly anxiety (44.4%), insomnia (22.5%), and depression (15.9%). The prescribing physicians were primarily psychiatrists (43.2%), followed by general practitioners (29.7%). Forty percent had been taking the drug for more than a year. Among those using BDZs for at least 1 month, 35.5% increased the dose with time. Thirty-three percent reported having experienced side effects. Eighteen patients (2.3%) reported taking more than one BDZ concomitantly, while 18.3% were taking drugs that should not be prescribed along with BDZs. In conclusion, the use of BDZs is highest among females, especially for the treatment of anxiety. Moreover, continuous use of the drugs for more than a year as well as significant potential drug interactions was identified.

Correlates of benzodiazepine use in major depressive disorder: The effect of anhedonia

BACKGROUND

Current treatment guidelines emphasize the limited role of benzodiazepines in Major Depressive Disorder (MDD), mainly due to the absence of long-term data, risk of abuse and potential adverse effects. However, benzodiazepines continue to be prescribed for long-term use in a significant number of patients. This study sought to evaluate benzodiazepine use in a large sample of MDD patients seen at a tertiary care clinic, and determine whether use is related to illness severity or complexity, as well as to identify the clinical predictors of benzodiazepine use.

METHODS

This was a naturalistic cross-sectional study conducted in MDD patients seen at the Mood Disorders Pyschopharmacology Unit at the University Health Network (N=326). Detailed information on current medication regimens was collected. A structured diagnostic interview, in addition to measures of symptom severity, quality of life, and personality were administered. Participants were grouped according to the presence or absence of prescribed benzodiazepines for daily use.

RESULTS

The prevalence of regular benzodiazepine use was 25%. Benzodiazepine users were more likely to be female, unemployed, have a history of child abuse, and have comorbid panic disorder. Depression and anxiety scores were not significantly different between groups, although anhedonia was greater in the benzodiazepine group. A logistic regression revealed anhedonia was the strongest predictor of regular benzodiazepine use.

CONCLUSION

The groups were similar in clinical profile suggesting benzodiazepine use is not necessarily linked to greater illness complexity or severity. Benzodiazepine use appears to be associated with specific diagnostic and symptom characteristics, possibly providing insight into the potential pharmacodynamic and neurobiological effects of frequent use.

Use of psychotropic medications in São Paulo Metropolitan Area, Brazil: pattern of healthcare provision to general population

PURPOSE

We estimate the proportion of psychotropic medication use (PMU) among adults in São Paulo Metropolitan Area, Brazil. We investigated whether socio-demographic factors, comorbidity, and disease severity influence PMU among individuals with psychiatric disorders.

METHODS

Data are from the São Paulo Megacity Mental Health Survey, a cross-sectional, population-based study, the Brazilian branch of the World Mental Health Survey Initiative. Trained lay interviewers face-to-face assessed psychiatric disorders and PMU through the Composite International Diagnostic Interview. Respondents were asked about use of healthcare service and prescribed medications for mental disorders in the previous year. Information on PMU was collected for 2935 adult residents in the area and among those with disorders who received treatment.

RESULTS

Around 6% of respondents reported PMU in the past year: hypnotics or sedatives were used by 3.7% and antidepressants by 3.5%. Among individuals with 12-month disorders, only 14% reported past year PMU. Gender, age, education, income, occupational status, comorbidity, and severity were significant predictors for PMU. Among those with 12-month DSM-IV disorders who obtained treatment in healthcare settings, almost 40% received medication only. Among those treated in specialty mental health service, around 23% received combination of medication and psychotherapy.

CONCLUSION

Our study has pointed out that the recent trend of access to mental healthcare in Brazil depicts unmet needs, characterized by a low prevalence of PMU among individuals with psychiatric disorders. Policies that improve appropriate access to prescribed drugs for those most in need are urgent public health priority.

Treatment of Anxiety Disorders in a Psychology Clinic

People with anxiety disorders demand psychological attention most often. Therefore, it seems important to identify both the characteristics of the patients who demand help and the clinical variables related to that demand and its treatment. A cohort of 292 patients who requested help at a university clinical facility was studied. The typical profile of the patient was: being female, young, unmarried, with some college education, and having previously received treatment, especially pharmacological one. The three most frequent diagnoses of anxiety, which include 50% of the cases, were: Anxiety Disorder not otherwise specified, Social Phobia, and Panic Disorder with Agoraphobia. Regarding the characteristics of the intervention, the average duration of the assessment was 3.5 sessions (SD = 1.2), and the duration of the treatment was 14 sessions (SD = 11.2). The percentage of discharges was 70.2%. The average cost of treatment was around €840. The results are discussed, underlining the value of empirically supported treatments for anxiety disorders.

Indication for pharmacological treatment is often lacking: a cross-sectional study on the quality of drug therapy among the elderly

BACKGROUND

Although the elderly have a substantially higher drug use than younger patients, even after adjustment for multimorbidity, there is limited knowledge about the elderly's indication for treatment. It is essential for elderly patients to have a well-planned drug therapy. The first step towards a correct and safe drug therapy is to ensure that the patient's drugs have an indication, i.e. correct diagnoses are linked to all of the prescription drugs. The aim of this study was to examine to what extent elderly patients have indication for a number of their prescribed drugs and, furthermore, if there are any differences in indication for treatment depending on gender, age, level of multimorbidity and income.

METHOD

Data were collected on individuals aged 65 years or older in Östergötland County in Sweden. To estimate the individual level of multimorbidity the Johns Hopkins ACG Case-Mix System was used. A report from the Swedish National Board of Health and Welfare was used to identify prescription drugs, for which it is important to have a correct diagnosis. The proportions of patients having indication for these prescription drugs were calculated. Odds ratios of having indication for treatment depending on gender, age, multimorbidity level and income were calculated.

RESULTS

On average 45.1 % (range 12.9 % - 75.8 %) of the patients' prescribed drugs had indication. Proton pump inhibitors were associated with the lowest level of indication (12.9 %) and digoxin was associated with the highest level of indication for treatment (75.8 %). Patients aged 80 years or older had the lowest odds ratios of having indication for treatment.

CONCLUSION

On average, there was indication for treatment in less than half of the prescription drugs studied. The quality was highest in relation to multimorbidity and lowest in relation to age. The result may to some extent be explained by substandard registration of diagnoses. Since lack of quality of prescription drug use is highly associated with inconvenience among the elderly, as well as high costs to society, it is important that future research and allocation of resources focus on the quality of elderly patients' drug therapy.

Benzodiazepine use in COPD: empirical evidence from Norway

BACKGROUND

The common comorbidities associated with COPD include, among others, anxiety, depression, and insomnia, for which the typical treatment involves the use of benzodiazepines (BZD). However, these medicines should be used with extra caution among COPD patients, since treatment with traditional BZD may compromise respiratory function.

AIMS

This study investigated the use of BZD among persons suffering from COPD by analyzing three relevant indicators: 1) the sum of defined daily doses (DDD); 2) the number of prescribers involved; and 3) the number of different types of BZD used.

DATA AND METHODS

The study builds on a linkage of national prescription data and patient-administrative data, which includes all Norwegian drug prescriptions to persons hospitalized with a COPD diagnosis during 2009, amounting to a total of 5,380 observations. Regression techniques were used to identify the patients and the clinical characteristics associated with BZD use.

RESULTS

Of the 5,380 COPD patients treated in hospital during 2009, 3,707 (69%) were dispensed BZD during the following 12 months. Moreover, they were dispensed on average 197.08 DDD, had 1.22 prescribers, and used 0.98 types of BZD during the year. Women are more likely to use BZD for all levels of BZD use. Overnight planned care not only increases the risk of BZD use (DDD), but also the number of prescribers and the types of BZD in use.

CONCLUSION

In light of the high levels of BZD prescription found in this study, especially among women, it is recommended that general practitioners, hospital specialists, and others treating COPD patients should aim to acquire a complete picture of their patients' BZD medication before more is prescribed in order to keep the use to a minimum.

Systematic review and meta-analysis of group cognitive behavioural psychotherapy treatment for sub-clinical depression

BACKGROUND

Studies investigating effectiveness of group psychotherapy intervention in sub-threshold depression have shown varying results with differing effect sizes.

AIMS

A systematic review of randomised controlled trials of group psychotherapy in adults with sub-threshold depression has been conducted to present the best available evidence in relation to its effect on depressive symptomatology and prevention of incident major depression.

METHODS

Electronic search for RCTs and a meta-analysis using random effects models to obtain a pooled estimate.

RESULTS

Eight studies from six clinical trials met the inclusion criteria. Group psychotherapy is an effective intervention for reducing depressive symptoms in adults with sub-threshold depression in comparison to waiting list controls (MD=-3.48, 95% CI: -5.02, -1.93). The reported benefits for group intervention in reducing depressive symptoms in comparison to other active interventions did not reach statistical significance (MD=0.37 95% CI: -1.29, 2.04). The benefit of group psychotherapy at follow-up is not maintained. Group psychotherapies do not appear to reduce the risk of incident depressive disorder during the follow up (RR=1.15 95% CI: 0.85, 1.54). Dutch studies had bigger effect sizes than studies from other countries. The quality of reporting of all the studies was suboptimal.

CONCLUSIONS

The results of this meta-analysis show that group CBT interventions for patients with sub-threshold depression have a significant effect on depressive symptomatology at post treatment in both working age and older adult population. However it does not appear to reduce the incidence of major depressive disorders and has minimal or no effect on depressive symptomatology during follow-up.